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Nearly three years have passed since the link was discovered, but veterinarians and animal welfare groups are still working to get the word out: Xylitol, a sugar substitute increasingly found in sugar-free cookies, mints and chewing gum – including Orbit, Trident, Spree and Altoids — can be highly toxic, even fatal, to dogs.

The sweetener, long popular in Europe and relatively new in the U.S., can be “very, very serious” to dogs when ingested, according to the Animal Poison Control Center of the American Society for the Prevention of Cruelty to Animals.

Two or three sticks of gum with xylitol can kill a 20 pound dog, the ASPCA says.

“It doesn’t take a whole lot, and the effects are so rapid that the window of opportunity to treat the dog is extremely small,” said ASPCA spokesperson Dana Farbman.

The ASPCA sent an advisory to veterinarians two years ago warning them about the potential for serious harm or death. But as with chocolate, grapes and raisins — all of which can be toxic to dogs — there are still dog owners who don’t know the dangers.

Within 30 minutes of consuming a small amount of a xylitol-sweetened product, the ASPCA says, dogs experience a dramatic drop in blood sugar, begin vomiting, become lethargic and can have difficulty standing or walking. Some have seizures, develop internal hemorrhaging and lesions and suffer liver failure.

USA Today wrote about the dangers of xylitol to dogs last year. At that time the ASPCA’s poison control unit was aware of 10 dog deaths from xylitol since 2002, and it has received scores of reports of dogs becoming gravely ill.

But the organization believes that represents only a small fraction of the cases.

Xylitol is derived from birch tree bark, beets, corncobs and other natural sources. Unlike sugar, xylitol does not require insulin to be metabolized, so it’s popular in cookies, candies, cupcakes and other sweets developed for people who have diabetes